DATE OF ADMISSION: MM/DD/YYYY
DATE OF DISCHARGE: MM/DD/YYYY
ADMISSION DIAGNOSES:
1. Pneumonia.
2. Reactive airway disease.
3. Dehydration.
DISCHARGE DIAGNOSES:
1. Interstitial pneumonitis.
2. Reactive airway disease, controlled.
3. Dehydration, resolved.
HISTORY OF PRESENT ILLNESS AND HOSPITAL COURSE: This is a (XX)-year-old Hispanic female infant who was brought to the ER, where she presented with a five-day history of runny nose, cough, fever, and increased respiratory distress. She had been seen by the primary care physician who had diagnosed her with viral illness and being treated symptomatically, but because she continued to worsen, she was brought to the ER where a chest x-ray revealed pneumonia.
The patient was given intramuscular antibiotics and discharged on Zithromax. Then, after completion of the Zithromax dosages, mother took her to the primary care physician to be rechecked because she was lethargic, not eating, and having diarrhea. She was then taken back to the ER, where a chest x-ray revealed a left lower opacity and peripheral white blood cell count of 4000. She was given IV fluids, IV dose of Rocephin and was admitted to the progressive care unit for further care.
The following workup was done on admission. CBC: WBC 4.5, H&H 12.2 and 37.4, platelet count 236,000 with 27% neutrophils, 65% lymphocytes, and 8% monocytes. Electrolytes with sodium of 120, potassium 4.2, chloride 90, CO2 of 9, glucose 120, BUN 8, creatinine 0.3, calcium 9.6. Troponin I 0.03. B-type natriuretic peptide 50. ACTH less than 2. A blood culture was obtained. A repeated CBC revealed a WBC of 5.8, H&H 11.8 and 36.8, platelet count 412,000 with 21% neutrophils, 1% bands, 67% lymphocytes, and 8% monocytes. Repeat electrolytes after rehydration was sodium of 138, potassium 4.6, chloride 106, CO2 of 22, glucose 150, BUN 7, creatinine 0.4, and calcium 9.2. A blood culture was reported as negative final.
A chest x-ray was done, which revealed no focal alveolar infiltrate in the left lower lobe, bilateral perihilar interstitial infiltrates consistent with viral pneumonitis. She was initially treated with Rocephin IV, which was discontinued two days prior to discharge. She was treated with Zithromax, for which she received a total of three dosages, Solu-Medrol IV. She was rehydrated with IV fluids. By the date of discharge, she was afebrile, vital signs stable, no longer in respiratory distress, and lungs were clear to auscultation.
DISPOSITION: The patient was discharged in a stable condition on Zithromax p.o. x4 days. Follow up with primary care physician in one week and p.r.n.
